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《中华消化外科杂志》2018年10月第17卷第10期论著

经颈静脉肝内门体分流术治疗肝移植术后再发门静脉高压症的临床疗效

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引用本文:
陈权,张裕,岳振东,等.经颈静脉肝内门体分流术治疗肝移植术后再发门静脉高压症的临床疗效[J].中华消化外科杂志,2018,17(10):1013-1017.DOI:10.3760/cma.j.issn.1673-9752.2018.10.009.
【摘要】

目的:探讨经颈静脉肝内门体分流术(TIPS)治疗肝移植术后再发门静脉高压症的临床疗效。
方法:采用回顾性横断面研究方法。收集2008年1月至2016年6月北京大学医学部第九临床医学院收治的15例TIPS治疗肝移植术后再发门静脉高压症患者的临床资料。TIPS:穿刺插管进行造影检查、测量门静脉压力并栓塞曲张静脉。应用直径7 mm或8 mm的球囊导管扩张预分流通道,植入直径7、8、 10 mm的覆膜支架或裸支架,建立分流通道;再次进行门静脉造影检查及测量门静脉压力。观察指标:(1)手术情况。(2)分流前后门静脉压力的变化情况。(3)随访和生存情况。采用门诊方式随访,记录患者术后1、3、6、 12个月的临床症状。术后1、3、6、12个月常规行肝血管超声检查明确分流道通畅情况。随访时间截至2018年6月。正态分布的计量资料以±s表示,采用配对t检验;偏态分布采用M(范围)表示。计数资料采用百分比表示。
结果:(1)手术情况:15例患者顺利完成TIPS,无严重合并症及死亡病例发生。支架植入情况:15例患者中,植入裸支架、覆膜支架和裸支架+覆膜支架建立分流通道的患者分别为4、8、 3例。15例患者中,建立直径7、8、 10 mm的分流道患者例数分别为4、8、3例。(2)分流前后门静脉压力的变化情况:15例患者门静脉压力由分流前(34±8)mmHg(1 mmHg=0.133 kPa)降至分流后(21±7)mmHg,分流前后比较,差异有统计学意义(t=7.07,P<0.05);门静脉压力梯度由分流前的(26±9)mmHg降至分流后(12±5)mmHg,分流前后比较,差异有统计学意义(t=6.43,P<0.05)。(3)随访和生存情况:15例患者均获得随访,随访时间为24.0~60.0个月,中位随访时间37.8个月。主要临床症状:12例消化道出血患者中,3例发生消化道再出血,均为分流道再狭窄或闭塞导致门静脉压力再次升高,9例未发生消化道再出血;5例门静脉血栓患者中3例血栓基本消失、2例明显减少(不影响血流);3例顽固性腹腔积液患者术后症状改善,其中2例术后5个月复发。术后分流道再狭窄或闭塞情况:15例患者中,7例术后发生分流道再狭窄或闭塞(含4例裸支架植入者),其中5例进行了分流道再开通,另2例患者无特殊临床症状,未进行治疗。肝性脑病发生情况:15例患者中,6例(1例7 mm分流道、3例8 mm分流道、2例10 mm分流道)发生肝性脑病,其中Ⅰ、Ⅱ、Ⅲ、Ⅳ级肝性脑病分别为2、3、0、1例。生存情况:15例患者中,1例术后6个月因肝衰竭死亡,3例分别在术后3、8、14个月再次行肝移植,余11例生存时间≥2年,存活最长者≥6年。
结论: 对于肝移植术后再发门静脉高压症患者,在其他方法疗效不佳的情况下,TIPS是一种安全有效的治疗方式。

【Abstract】

Objective:To investigate the clinical efficacy of transjugular intrahepatic portosystemic shunting (TIPS) for recurrent portal hypertension after liver transplantation.
Methods:The retrospective crosssectional study was conducted. The clinical data of 15 patients with recurrent portal hypertension after liver transplantation who underwent TIPS in the 9th School of Clinical Medicine between January 2008 to June 2016 were collected. Course of TIPS: the portal vein pressure was measured and varicose veins were embolized after puncture, cannulation and angiography. A balloon catheter with diameter of 7 mm or 8 mm was used to dilate the preshunt channel, and a covered stent or bare stent with a diameter of 7, 8 or 10 mm was implanted to establish the shunt channel. Portal vein angiography was performed and the portal vein pressure was measured again. Observation indicators: (1) Surgical situations; (2) changes of portal vein pressure before and after TIPS; (3) followup and survival situations. Followup using outpatient examination was performed to record clinical symptoms at postoperative 1, 3, 6 and 12 months. Regular hepatic vascular ultrasonography was done at postoperative 1, 3, 6 and 12 months to detect patency of shunt. The followup period was up to June 2018. Measurement data with normal distribution were represented as ±s and analyzed by the paired t test. Measurement data with skewed distribution were described as M (range). Count data were represented as percentage.
Results:(1) Surgical situations: all the 15 patients underwent successful TIPS, without any serious complications or death. Stent implantation situation: bare stent, covered stent and bare stent + covered stent were implanted in 4, 8 and 3 patients, respectively. Among the 15 patients, 7 mm, 8 mm and 10 mm diameter shunt channel were established in 4, 8 and 3 patients respectively. (2) Changes of portal vein pressure before and after TIPS: portal vein pressure of the 15 patients decreased from (34±8)mmHg (1 mmHg=0.133 kPa) to (21± 7)mmHg before and after TIPS, with a statistically significant difference (t=7.07, P<0.05). Portal vein pressure gradient decreased from (26± 9)mmHg to (12±5)mmHg before and after TIPS, with a statistically significant difference (t=6.43, P<0.05). (3) Followup and survival situations: 15 patients were followed up for 24.0- 60.0 months, with a median followup time of 37.8 months. Main clinical symptoms: of 12 patients with gastrointestinal hemorrhage, 3 had gastrointestinal rehemorrhage mainly due to portal vein pressure rising again caused by shunt restenosis or occlusion, 9 had no gastrointestinal rehemorrhage. Of 5 patients with portal vein thrombosis, thrombus was disappeared basically in 3 patients and decreased obviously (no effect on blood flow) in 2 patients. Three patients with refractory ascites were effectively improved after TIPS, however, 2 of them were recurred at postoperative 5 months. Postoperative restenosis or occlusion of shunt channel: among 15 patients, 7 developed restenosis or occlusion of the shunt channel (including 4 with bare stents). Five of them underwent shunt recanalization and another 2 without special clinical symptoms had no treatment. Hepatic encephalopathy: 6 of 15 patients including 1 with 7 mm shunt, 3 with 8 mm shunt and 2 with 10 mm shunt developed hepatic encephalopathy, of which grade Ⅰ, Ⅱ, Ⅲ, and Ⅳ hepatic encephalopathy were detected in 2, 3, 0 and 1 patients, respectively. Survival situations: of the 15 patients, 1 died of hepatic failure at postoperative 6 months, 3 were performed liver transplantation again at postoperative 3, 8 and 14 months, respectively, 11 survived more than 2 years with the longest survival time more than 6 years.
Conclusion:TIPS is safe and effective for recurrent portal hypertension after liver transplantation for patients who have not effective other treatment.

DOI:10.3760/cma.j.issn.1673-9752.2018.10.009
基金项目:国家自然科学基金(81871461);首都医学发展科研基金(2018-1-2081)
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